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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 14  |  Issue : 4  |  Page : 176-181

Ventilation tubes versus cartilage tympanoplasty with cortical mastoidectomy: a clinical and audiological comparative study in the treatment of middle ear atelectasis


1 Department of Otorhinolaryngology, Al-Azhar University, Assuit, Egypt
2 Department of Audiology, Assuit University, Assuit, Egypt

Date of Submission21-Dec-2016
Date of Acceptance02-Feb-2017
Date of Web Publication23-Jun-2017

Correspondence Address:
Abdelaziz Mohamed Hassan Elsherif
Derpartment of Otorhinolaryngology, Al-Azhar University, Assuit, 61237
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-1693.208936

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  Abstract 

Background Atelectasis of the middle ear is a collapse of the middle ear space formed by extreme atrophy of the tympanic membrane. It is still a controversial issue regarding its etiology, and little has been published about its progression.
Objective The aim of the study was to compare clinical and audiological outcomes in the treatment of atelectatic ear using ventilation tube versus cartilage tympanoplasty with cortical mastoidectomy.
Patients and methods This study was conducted on 40 ears with atelectasis, diagnosed clinically, endoscopically, and audiologically. Twenty ears were subjected to ventilation tube insertion and the other 20 ears underwent cartilage tympanoplasty with cortical mastoidectomy. An audiogram was done 3 months postoperatively after the graft was fully taken and was then repeated after 6 months.
Results Group 1 (cartilage tympanoplasty with cortical mastoidectomy group) included 20 ears, and group 2 (ventilation tube insertion group) included 20 ears. For group 1, the clinical results were the same at 3 and 6 months. Graft was taken in 18 (90%) ears and was broken with residual perforation in two (10%) cases. Mean hearing gain for this group was 17.44±7.35 dB after 3 months and 22.25±6.59 dB after 6 months. Mean air–bone gap was 22.25±3.55 dB preoperatively, 7.56±5.55 dB at 3 months, and 6.75±5.76 dB after 6 months.
For group 2, after 3 months the tube was in place in all cases (100%). After 6 months, the tube was in place in 16 (80%) ears. There was extrusion in four (20%) ears − two (10%) of them had residual perforation, one (5%) had recurrent disease, and one retained normal hearing. Mean hearing gain for group 2 was 25.01±4.51 dB at 3 months and 21.83±5.42 dB at 6 months postoperatively. Air–bone gap was 21.14±3.48 dB preoperatively, 3.69±1.84 dB at 3 months, and 5.81±1.78 dB after 6 months.
Conclusion Tube insertion showed a better clinical prognosis in second-stage atelectatic ears than in the third-stage ears. On the other hand, cartilage tympanoplasty showed better clinical prognosis in third-stage atelectatic ears than in second-stage ears.

Keywords: cartilage tympanoplasty, cortical mastoidectomy, middle ear atelectasis, ventilation tubes


How to cite this article:
Wafaie MM, Elsherif AM, Othman Y, Bakr MS, Hussien M. Ventilation tubes versus cartilage tympanoplasty with cortical mastoidectomy: a clinical and audiological comparative study in the treatment of middle ear atelectasis. Al-Azhar Assiut Med J 2016;14:176-81

How to cite this URL:
Wafaie MM, Elsherif AM, Othman Y, Bakr MS, Hussien M. Ventilation tubes versus cartilage tympanoplasty with cortical mastoidectomy: a clinical and audiological comparative study in the treatment of middle ear atelectasis. Al-Azhar Assiut Med J [serial online] 2016 [cited 2019 Sep 22];14:176-81. Available from: http://www.azmj.eg.net/text.asp?2016/14/4/176/208936




  Introduction Top


Atelectasis of the middle ear, synonymous with that of the lung, is a variable collapse of the middle ear space, associated with retraction pockets formed by extreme atrophy of the tympanic membrane (TM). There is almost always an associated otitis media with effusion [1]. Atelectasis of the middle ear due to atrophy and retraction of the TM is a common problem in otolaryngology [2]. Due to the columella effect of the atrophic membrane draped over the ossicular chain, hearing levels are a poor indicator for the severity of the disease [3]. Several classification systems exist for middle ear atelectasis. Sadé and Berco [4] proposed the first classification system that graded retractions. In 1982, Tos [5] described a classification system solely devoted to Shrapnell’s membrane.

The Tos classification

Tos I: pars flaccida not in contact with malleus head.

Tos II: pars flaccida in contact with malleus head.

Tos III: limited outer attic wall erosion.

Tos IV: severe outer attic wall erosion [5].

In 2000, Dornhoffer described a classification system for pars tensa retractions that was similar to Sade’s but differed in its representation of the worse atelectatic ears [6]. Both classifications, Sade’s and Dornhoffer’s, described the atelectatic ear that has a drum that is retracted but does not touch any middle ear structures, as grade I. In a grade II atelectatic ear, the drum is retracted and touches the incus or stapes. In a grade III retraction, the drum progresses inward and touches the promontory. The description of the grade IV atelectatic ears is the point where Sade’s and Dornhoffer’s classification systems diverge. In a grade IV atelectatic ear, the drum is retracted around the edge of the scutum, and all aspects of the drum cannot be visualized. Sade uses the grade IV classifications to describe an atelectatic ear that has a TM adheased to the middle ear structures, but does not comment on whether the entire drum can be seen easily. Dornhoffer, on the other hand, is less concerned about the adhesive properties of the TM, but is more concerned that all aspects of the drum can be visualized adequately [6],[7]. Visualizing all aspects of the drum is more important than its adhesive properties. Once the drum retracts beyond what can be visualized, the physician has no way of adequately assessing the size or depth of the retraction. The leading edge of a retraction may be just beyond the physician’s line of sight, or the retraction may be quite large and fill the epitympanum and mastoid [8]. There are several management options, varying from watchful waiting, through surgical intervention in form of ventilation tube insertion, to simple excision and ventilation tube insertion, myringoplasty, and tympanoplasty (with or without cartilage support and pallisades), or cortical mastoidectomy in an attempt to improve middle ear ventilation [3]. As Dornhoffer has stated in a previous study, there is also a dilemma about the most suitable moment for intervention. Some clinicians prefer watchful waiting, with their rationale being to avoid the potential risk for iatrogenic hearing loss in an ear that is often otherwise relatively asymptomatic [6]. Others prefer early intervention to limit the chances of incus erosion or progression of disease toward cholesteatoma formation [9].

The aim of this study was to compare the clinical and audiological outcomes in treatment of atelectatic ear using ventilation tube versus cartilage tympanoplasty with cortical mastoidectomy.


  Patients and methods Top


This study was carried on 33 patients with middle ear atelectasis, diagnosed clinically, endoscopically, and audiologically among patients selected from the ENT Outpatient Clinic of Al-Azhar University Hospital (Assiut). Approval of the ethical committee was obtained with patient consents collected before the start of the study. Exclusion criteria included previous ear surgery (except ventilation tube insertion), chronic suppurative otitis media, sensorineural hearing loss, or cholesteatoma. In total, 26 patients underwent unilateral operation (17 cartilage tympanoplasty with cortical mastoidectomy and nine ventilation tube insertion); six had bilaterally similar operations (five had bilateral tube insertion and one patient had bilateral cartilage tympanoplasty with cortical mastoidectomy); and, lastly, one patient had a tube in one ear and cartilage in the other. Twenty ears underwent tragal cartilage tympanoplasty with cortical mastoidectomy (group 1), whereas the other 20 ears were subjected to ventilation tube insertion (T-tube) (group 2). Postoperative audiogram was done 3 months postoperatively after the graft had been fully taken and was repeated after 6 months.

Postoperative prophylactic broad spectrum antibiotics were administered for all patients to avoid postoperative sepsis.

Follow-up visits were scheduled after 1 week, 2 weeks, 1, 3, and 6 months. A postoperative audiogram was obtained 3 months later, and the ears were examined microscopically. The ears also were examined at 6 months and other audiological assessments were carried out. The differences between the preoperative and postoperative air–bone gaps (ABGs) were also calculated.


  Results Top


The study included 40 affected ears in 33 patients.

Demographic data of both study group patients are summarized in [Table 1].
Table 1 Age and sex of the study groups

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Grouping of the study cases as regards clinical stage is shown in [Table 2] and [Figure 1].
Table 2 Clinical stages and types of operations of operated ears

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Figure 1 Clinical stages and types of operations of operated ears

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Clinical results of group 1

The clinical results were the same at 3 and 6 months postoperatively. Grafts were taken in 18 (90%) ears and were broken with residual perforation in two (10%) ears.

Clinical results of group 2

At 3 months, tubes were in place in all ears (100%). At 6 months, tubes were in place in 16 (80%) ears. There were extrusion in four (20%) ears − two (10%) of them had residual perforation and one (5%) had recurrent disease. The last ear retained normalcy. The ears that had residual perforations and recurrent disease were diagnosed preoperatively as third-stage atelectasis.

As regards incidence of complications in group 1, complications were found in two cases as graft rejection, whereas the type and incidence of complications in group 2 are shown in [Table 3].
Table 3 Complications of tube insertion and their percentage

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Audiological results

[Table 4] and [Table 5] and [Figure 2] and [Figure 3] show a comparison between the mean hearing gain and mean ABG for the two groups.
Table 4 Mean hearing gain at 3 and 6 months in both groups

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Table 5 Mean air–bone gap in both groups

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Figure 2 Mean hearing gain at 3 and 6 months postoperatively in both groups

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Figure 3 Mean air–bone gap in both groups

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In [Table 5] we compared mean ABG preoperatively and postoperatively for the two groups.


  Discussion Top


Atelectasis of the middle ear is a common problem in otolaryngology. However, there is no consensus as to the best treatment strategy [2]. There are several options, varying from watchful waiting, to surgical intervention in the form of ventilation tube insertion, simple excision and ventilation tube insertion, myringoplasty and tympanoplasty (with or without cartilage support and palisades), or cortical mastoidectomy in an attempt to improve middle ear ventilation. Due to the columella effect of the atrophic membrane draped over the ossicular chain, hearing levels are a poor indicator for the severity of the disease [3]. There is also a dilemma about the most suitable moment for intervention. Some clinicians prefer watchful waiting, with their rationale being to avoid the potential risk for iatrogenic hearing loss in an ear that is often otherwise relatively asymptomatic [6]. Others prefer early intervention to limit the chances of incus erosion or progression of disease toward cholesteatoma formation [9].

Traditional surgical treatment of TM atelectasis involves ventilation tube insertion followed by formal tympanoplasty if atelectasis fails to resolve. However, atelectasis occasionally persists despite excellent aeration; this may be caused by the flaccid and redundant character of the TM, or fibrous adhesions between the undersurface of the membrane to the bony structure in the middle ear. In addition, atelectasis would occasionally recur soon after tube extrusion or occlusion if ventilation tube insertion is the sole treatment, without addressing the membrane weakness or redundancy [10]. It was better to choose a grafting material that could resist the continuous negative middle ear pressure. Because cartilage is rigid and more stable, it might be a better choice than fascia to resist the negative middle ear pressure that is almost always observed in atelectatic ear [11].

In the current study we compared between the two most common surgical solutions for this confusing disease. This comparison was for the two main characters of importance for any otologist, that is, the clinical (healing) aspect and the audiological (hearing) aspect.

Totally, 40 ears of 33 patients suffering from hearing loss (conductive type) and presenting with middle ear atelectasis were operated upon and were followed up for 6 months. Postoperative pure tone audiometry was carried out at 3 and 6 months postoperatively. Hearing gain and ABG were calculated. These 40 ears were divided into two groups. The first group, including 20 ears, underwent cartilage tympanoplasty using tragal cartilage associated with cortical mastoidectomy.

Whereas the second group, including the other 20 ears, underwent long-standing ventilation tube (T-tube) insertion through classical myringotomy incision.

In the first group, 19 patients underwent cartilage tympanoplasty with cortical mastoidectomy. Eighteen of them had operation in one ear, whereas the last patient had bilateral cartilage tympanoplasty. Their age range was from 15 to 48 years, with a mean age of 24.1±11.8 years. For the same group we operated 11 (55%) ears of men and nine (45%) ears of women; eight (40%) of second-stage and 12 (60%) of third-stage atelectasis, according to Sade’s classification.

For the first group, as regards clinical and audiological results, there was no significant difference at 3 and 6 months postoperatively. As regards clinical results, tragal cartilage grafts were taken in 18 (90%) ears, whereas break with residual perforation occurred in two (10%) cases. This result was nearly in agreement with that of Dornhoffer [12] who, in his 1000-case series, reported that an atelectatic TM was the surgical indication in 15%, of which 20% were revision cases and two-thirds were in children. The success rate was more than 95% for graft take, with good hearing results. Reformation of the retraction pocket was extremely rare, but 7% of patients required postoperative tube insertion owing to persistent effusion [12].

This result also was nearly in agreement with that of Elsheikh et al. [13] who operated 23 cases and reported that in the atelectatic ear, cartilage allowed reconstruction of the TM with good anatomical and functional results with recurrent disease in three cases. Ozbek et al. [11] reported that tragal cartilage is locally available in amounts adequate for cartilage tympanoplasty using the cartilage–perichondrium composite graft and no physical deformity is left at the donor site. In addition, perichondrium attached to cartilage aids survival and is the rationale for leaving the perichondrium attached to the cartilage in reconstruction of the TM. Furthermore, the apron of perichondrium helps to stabilize the graft [11].

The perichondrium–cartilage composite graft is nearly always constructed with cartilage harvested from the tragus. This cartilage is ideal because it is thin, flat, and in sufficient quantities to permit reconstruction of the entire TM. Although significant conductive hearing loss with a TM that is rigid and thick is predicted, hearing results after cartilage tympanoplasty have been shown to be satisfactory [14].

As regards audiological results, there was significant hearing improvement postoperatively. However, there was no significant difference in results at 3 and 6 months postoperatively. There was an improvement in hearing postoperatively, which was presented with increased hearing gain. The mean hearing gain for this group was 17.44±7.35 dB at 3 months and 22.25±6.59 dB at 6 months postoperatively. There was a significant improvement of hearing with closure of ABG at 3 and 6 months. The mean ABG was 22.25±3.55 dB preoperatively, 7.56±5.55 dB at 3 months, and 6.75±5.76 dB at 6 months postoperatively.

The role of cortical mastoidectomy in the treatment of chronic nonsuppurative otitis media is a matter of controversy. Few articles were published about that and most of them were about the role of cortical mastoidectomy in the treatment of noncholesteatomatous chronic otitis media. We carried out cortical mastoidectomy with cartilage tympanoplasty to ensure good aeration of the middle ear. Along with this study, Sheehy [15] recommended performing simple cortical mastoidectomy routinely for all tympanoplasties because it is ‘good practice’ and because ‘it’s better to be safe than sorry’.

In the second group 15 patients underwent T-tube insertion. Ten of them had operation in one ear whereas the other five had bilateral insertion of the T-tube. Their age range was from 10 to 50 years, with a mean age of 22.6±13.7 years. For the same group we operated four (20%) ears of men and 16 (80%) of women, 13 (65%) second-stage and seven (35%) third-stage atelectasis, according to Sade’s classification.

As regards clinical results at 3 months postoperatively, the second group showed a marked improvement. Tubes were in place in all ears (100%). Despite the presence of postoperative otorrhea in three (15%) ears, the infection was well controlled using local and systemic antibiotics and there was no need to remove the tubes. This incidence of infection was superior to that of Bluestone [16] who recorded 30% of ears with postoperative otorrhea after using classic Goode T-tube. However, after 6 months, there was deterioration as complications had occurred. There was extrusion in four (20%) ears − two of them had residual perforation (10%), one had recurrent atelectasis (5%), and the last one regained normal in hearing. The ears that had residual perforation and recurrent disease were third-stage atelectasis preoperatively. As we mentioned above, there was extrusion of tube in four (20%) ears. This was in agreement with the findings of Sederberg-Olsen et al. [17] who found 18% extrusion after insertion using Goode T-tubes.

Using the classic operative technique of Goode T-tube insertion, Leopold and McCatx [18] reported that extrusion occurred earlier in the thin TM; they suggested that the fibrous middle layer of the TM was weakened by ventilation tube insertion, leading to earlier ventilation tube extrusion and a greater likelihood of persistent perforation. This gave us a reasonable interpretation that all cases of extrusion were in ears with third degree atelectasis as the TM became thinner [18]. There were two (10%) ears with persistent perforation, which were left as natural ventilation tube. These results were superior to that of Courteney-Harris and colleges who reported 15% residual perforation after insertion of T-tubes [19],[20]. Tubal blockage was present in one (5%) ear, which was in agreement with the results obtained by Isaacson [21] who reported 7% tubal occlusion as a complication of tube insertion.

As regards audiological results at 3 months postoperatively, the second group showed a marked improvement, which decreased after 6 months because of the presence of complications (extrusion of tube with residual perforation and recurrence). There was an immediate marked improvement of hearing postoperatively up to 3 months that was presented with increased hearing gain. However, this hearing gain declined at 6 months because of complications. The mean hearing gain for the second group was 25.01±4.51 dB at 3 months and 21.83±5.42 dB at 6 months postoperatively. There was a significant improvement of hearing with near closure of the ABG at 3 months and at 6 months but with a lesser degree as there were three cases with perforation and recurrent disease. The mean ABG was 21.14±3.48 dB preoperatively, 3.69±1.84 dB at 3 months, and 5.81±1.78 dB at 6 months postoperatively. These audiological results (100% of patients at 3 months and 85% of patients at 6 months) were in agreement with that of Goode [22] who used the Goode T-tube for long-term ventilation of the middle ear by classic technique. He reported 87% of the patients with normal hearing threshold 1-year postoperatively [22]. Bluestone and colleagues reported almost similar results after use of long-term ventilation tube in the treatment of recurrent effusion and atelectatic ear [16],[23].


  Conclusion Top


T-tube insertion had a better clinical prognosis in second-stage atelectatic ear than in third-stage ears. On the other hand, cartilage tympanoplasty had a better clinical prognosis in third-stage atelectatic ears than in second-stage ears.

Further studies of longer duration should be carried out using a larger number of patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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3.
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4.
Sadé J, Berco E. Atelectasis and secretory otitis media. Ann Otol Rhinol Laryngol 1976; 85:66–72.  Back to cited text no. 4
    
5.
Tos M. Atrophy of the tympanic membrane in surgery and pathology of the middle ear. New york ,USA: Presented at the International Conference on the Post-Operative Evaluation in Middle Ear Surgery; 1982.  Back to cited text no. 5
    
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Dornhoffer JL. Surgical management of the atelectatic ear. Am J Otol 2000; 21:315–321.  Back to cited text no. 6
    
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Danner CG. Middle ear atelectasis: what causes it and how is it corrected? Otolaryngol Clin North Am 2006; 39:1211–1219.  Back to cited text no. 8
    
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Borgstein J, Gerritsma TV, Bruce IA, Feenstra L. Atelectasis of the middle ear in pediatric patients: safety of surgical intervention. Int J Pediatr Otorhinolaryngol 2009; 73:257–261.  Back to cited text no. 9
    
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11.
Ozbek C, Ciftci O, Ozdem C. Long-term anatomic and functional results of cartilage tympanoplasty in atelectatic ears. Eur Arch Otorhinolaryngol 2010; 267:507–513.  Back to cited text no. 11
    
12.
Dornhoffer J. Cartilage tympanoplasty: indications, techniques, and outcomes in a 1,000-patient series. Laryngoscope 2003; 113:1844–1856.  Back to cited text no. 12
    
13.
Elsheikh MN, Elsherief HS, Elsherief SG. Cartilage tympanoplasty for management of tympanic membrane atelectasis: is ventilatory tube necessary? Otol Neurotol 2006; 27:859–864.  Back to cited text no. 13
    
14.
Ozbek C, Ciftci O, Tuna EE, Yazkan O, Ozdem C. A comparison of cartilage palisades and fascia in type 1 tympanoplasty in children: anatomic and functional results. Otol Neurotol 2008; 29:679–683.  Back to cited text no. 14
    
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Sheehy JL. Surgery of chronic otitis media. In: English G, editor. Otolaryngology. Philadelphia: Harper and Row; 1985. 1:pp. 1–86.  Back to cited text no. 15
    
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Bluestone CD. Tympanostomy tubes and related procedures. Atlas Ped Operative Otolaryngol 2002; 1:4–18.  Back to cited text no. 16
    
17.
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Goode RL. Long-term middle-ear ventilation with T-tubes: the perforation problem. Otolaryngol Head Neck Surg 1996; 115:500–501.  Back to cited text no. 22
    
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Rosenfeld RM, Schwartz SR, Pynnonen M. Clinical practice guideline: tympanostomy tubes in children. Otolaryngol Head Neck Surg 2013; 149:51.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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